Monday, July 4, 2016

Closing In On Retirement

A happy retirement dream:  I am walking along the edge of a canyon that I have walked many times before.  In physical reality this canyon does not exist.  There is a large herd of buffalo stampeding through the canyon and making a lot of noise.  On the opposing ridge there are 5 or 6 wolves trailing the herd.  I see a family to my right and step into their yard to warn them about the wolves.  The father reassures me that everything is under control and there is nothing to worry about.  He has three small children playing behind him.  He introduces me to a friend who I recognize from college and who has not aged well.  I am sure that I remember his name but don't say it just in case I am mistaken.  I realize that I am late and need to take a test, but it is a long way back to town.  I think about asking my brother to pick me up and take me there - but I am already 15 minutes late.....

Closing in on retirement is not what I expected.  I can remember sitting in 8th grade English class and wondering what it would be like to live to the old age of 40.  Now that I am well past that and surprisingly healthy what is the best way to transition?  Many people who retire these days are in a similar position. Chronic illnesses are better managed and most people anticipate a phase of active retirement, before moving on to less activity.  One of the critical questions is how to make that transition as a professional.  Besides feeling fairly healthy and fit, I also feel like I am at the top of my game as a psychiatrist.  At a time when most psychiatrists are over the age of 55, should I try for a more gradual transition from patient care and teaching?  Or should I just walk away?  A lot of people seem to think that they have the answer.  They have observed my work habits that included too many hours and too few compromises and have concluded "You will never retire!"  The psychiatric colleague who I have known the longest has concluded that about herself.  She thinks that she will end up being  carted away some day from the job that she has worked for decades.  I know I could not do that because I walked away from that setting 6 years ago - burned out and fully intending to call it quits.  When you work a job for 22 years, it is easy to lose sight of the fact that there are many more reasonable jobs out there.  Some of us just hunker down in longevity mode and don't see it until a crisis hits.

I put some preliminary communications out there.  I concluded a couple of years ago that the most rewarding and efficient use of my time would be teaching - preferably psychiatric residents.  Residency programs are much different today than when I was a resident.  Business management has basically corrupted them.  Today it is virtually impossible to be teaching clinical faculty anywhere and not have the same productivity expectations as psychiatrists in private practice.  In other words there is the expectation that you can see large numbers of patients and continue be an innovative and creative teacher.  Your salary is "justified" by the amount of billing that is generated.  That has never really worked for me.  I just attached one of my old storage devices to my current network this afternoon.  Sitting there on that drive was a series of 10 PowerPoints on psychopharmacology from 2008.  They were all 2 hour lectures and I came up with them from scratch after meeting with the residency director of a program I was affiliated with.  The residents that year had requested that I teach the psychopharmacology lectures.  I had peripheral involvement with the program until that point - largely due to the administrative restrictions.  She thought it was really important for me to do it and I agreed that I would, but it was a significant time penalty for me.  There was no productivity credit for preparing and delivering the lectures and no additional reimbursement.  It was all done on my own time after taking care of all of the clinical work, billing and documentation.  All done late at night and on the weekends - free gratis.  Despite that, I was confident that I did a good job and the residents appreciated the work.

The point I am at in psychiatry, I am confident that I can teach nearly anything and do a good job of it.  I am not confident at all that I want to transition into retirement seeing 75 - 100 very ill polypharmacy patients and teaching residents how to tweak that polypharmacy.  You really don't need an experienced and knowledgeable psychiatrist to do that.  I know that this is not really psychiatry, but somebody's business model of how to generate revenue and not consider all of the information that merits consideration.  I can't sit by and look at people who have never had a manic episode being misdiagnosed with bipolar disorder, or the endless people with chronic stress in their lives expecting that medication will somehow change that, or the high functioning person with "ADHD" who really wants a prescription for a stimulant so they are not at a competitive disadvantage in college or professional school.  Beyond that - I can't bite my tongue and listen to how they are seeing a therapist who is a "sounding board" and endlessly rehashing either their childhood or what happened last week and how that is supposed to be productive psychotherapy.  I can tell them what they need to do to get better and if necessary do the therapy myself.  And then there are the people with non-epileptic seizures, psychogenic mutism, chronic Lyme's disease, chronic pain, chronic daily headaches, reflex sympathetic dystrophy/complex regional pain syndrome and endless somatic permutations that need psychiatric care but walk in saying they don't: "I am here because my doctor thinks this is all in my head".  There are the people with delirium, dementia, movement disorders, and abnormal MRI scans.  I can see all of those people until my dying day, but it does not make an impact unless what I know can be amplified through current residents.

Before business managers ran medicine there was the kind of room I need at the current stage of life.  Senior staff in those days were the people the house staff and attendings consulted.  The absolute best teaching team that I ever worked on was a Nephrology team at Froedtert Hospital in Milwaukee.  It was my last rotation in medical school.  I recall finishing rounds at 10:30PM on the night before graduation and walking across the county hospital grounds to my apartment like it was yesterday.  That team was staffed by two senior Nephrologists in their late 60s.  The remaining team members included a Nephrology Fellow, two internal medicine residents, an intern and me.  There was no myth that these senior staff somehow knew less or were less relevant.  It was quite the opposite.  We rounded twice a day until all of the consults and hospitalized patients were covered and the senior staff were the primary discussants.  That myth is alive and well today, largely as a means to disenfranchise the tested clinical methods in medicine and make future generations of physicians dependent on organizations run by business managers rather than colleagues.  Organizations that have promoted the idea that tests and arbitrary and unvalidated performance metrics are more important than spending enough time with patients and enough time discussing clinical scenarios with a broad range of physicians including the most experienced colleagues.  It is no coincidence that the myth thrives in non-academic hospital environments staffed by generalists working impossible shifts.  Knowledge and academics seems at its leanest point in the past 50 years.  

At this point I am resigned to do what I can.  I have offered my services but there are a significant number of reasons why none of that may come to pass.  The hardest thing about retirement for me comes down to three issues.  First, there are not nearly enough people to take my place.  Psychiatry is possibly the best example of how a field can be decimated by political and business influences even in the midst an obvious shortage of services.  Throughout my entire career there has been a shortage of psychiatrists and nobody has done a thing about it.  Second, the very inefficient transfer of knowledge.  I was personally taken out of the teaching loop for a long time by business practices that made it impossible for me to teach.  What I know is not written down in texts and if I don't pass it along - it dies with me.  That is counter to the evolution of how knowledge is passed from one generation to the next.  Only American politics and business practices can stop evolution in its tracks.  Finally, being an active part of a person's treatment and recovery from mental illness is important to me.  In every case that involves an internal process on the part of the psychiatrist.  In retrospect, I have attributed it to having great teachers and colleagues, a great memory, a particular personality characteristic, scholarship, or just being compulsive.

Despite what the measurement based people say, the validation of that process is totally subjective.  At the end of the day or years/decades later - it is a person saying that you made a difference in their life and knowing that happened because you gave them the best medical advice that you could at the time.  For me personally, it has also meant seeing people who have the most severe problems.

I won't miss any of the productivity based work any more than if I walked off any assembly line.

George Dawson, MD,  DFAPA


I realized in the last couple of years that this blog factors into the transition as well.  People have always asked me how I know something when I quote research or suggest a particular treatment or method of analysis.  I think that part of what I am doing here on these pages is illustrating how I know something.  Hopefully fellow psychiatrists, but especially medical students and residents will find it useful.


The graphic at the top of this post was downloaded from Shutterstock on July 4, 2016.



  1. As a former residency training director (for 16 years) whose program was decimated after I left, I can only say, "Amen!"

    1. Thanks for that comment David.

      I am amazed that hardly anyone comments on what has happened and how an intellectually bankrupt managed care system has affected what used to be academic medicine.

      The only thing worse is that they are trying to brand and sell it as their own special type of pseudoscience making it up as they go along. Neither of the nephrologists who I worked with would have tolerated a case manager with no medical credentials sitting in on their rounds and telling them what to do.

      I would hope that former residency directors across medicine would break the silence and tell the public what has happened here.

    2. I can't speak for what happened in other programs, but the private practice organization for the University doctors where I worked started creating havoc for me and for the residency program not too long after they purchased an HMO for the new state medicaid program (Tenncare).

      Having already experienced the foul play of managed care companies when I was in private practice in California where it all first started, I was warning the other academic psychiatrists about it, but no one would listen to me!

      Soon the doctors were working for the administrators instead of the other way around as it had been, and money started drying up everywhere. A departmental surplus of a million dollars went up in mysterious smoke. Doctors who had been earning bonuses for doing extra work were suddenly expected to keep up the same level of "productivity" without being paid the extra cash!! (I never had worked extra since I am definitely not a workaholic, so it did not affect me).

      Once I had tenure a while later, I merely reiterated the terms on which I had been hired originally whenever I was attacked (on a yearly basis) for not seeing enough patients. To get me to shut me up, since they knew I had them dead to rights and would not cave like some of the other docs did, the department and the dean kept increasing the state dollars I received in salary for being training director as they decreased the dollars I earned from the practice group! I kept seeing the same number of patients I always had regardless. And I still did psychotherapy, which they hated since it wasn't as lucrative for them.

  2. It's a wonderful post, and I'm so sad. All I could think was, I hope you can expand on the blog in some way that medical students and residents can access, and I hope there are students and residents out there who will recognize the value of that kind of teaching.

    1. I don't know about expansion. I think that timing is everything. I used to think that there was some magic to the number of posts, but now I think the best plan to to work at quality posts.

      I have generally been impressed with the students and residents that I have interacted with. I know the two things I can't give them are:

      1. My experience on that Nephrology service and in fact many services I was on in medical school where it was exciting to go to work because of a highly stimulating academic environment. I don't know how that happens these days in morning huddles with case managers talking about who needs to be discharged due to whose rationing algorithm.

      2. Working in an environment without the intrusion of business managers trying to demonstrate why they are needed. When academic medicine dominated the landscape - all of the bean counting still happened. There were no financial crises like the ones that routinely occur today. We were not restricted to providing a "little bit" of psychiatric services. The managerial class seems to be detrimental not just to a scholarly approach to medicine, but also to the financial management of the health care system.

  3. Hi Dr. Dawson. I'm a recent medical student and now psychiatry resident - for what it's worth, I follow your blog regularly and I find your clinical wisdom a rare and refreshing find. Thanks for what you do, and I wish you luck in finding a good place for your knowledge to thrive as you transition to retirement.

  4. Graduating residents take heed! From a Forbes article called "Ten Unmistakable Signs of a Bad Place to Work:"

    Formal Performance Management

    Performance Management is the name of a popular HR hoax and scam that turns any job into a series of tasks and goals that you’ll be held accountable for on a daily, weekly and monthly basis. No job worth doing breaks down into tiny, measurable parts.

    Good jobs are whole. You know what your mission is and you work toward your mission every day, checking in with your manager as appropriate. Run away from any company that surrounds you with yardsticks and measurements. Working in a place like that would only raise your blood pressure and destroying your mojo.

    1. Agree completely David.

      It is all part of the pseudoscience of the managerial class in America.

      I can recommend a book in this area called "Get Rid Of The Performance Review!" that talks about the obvious biases and problems with so-called performance reviews. I worked in a setting where they were implemented and fellow employees who may or may not know you were asked to write anonymous reviews of your deficiencies! It was clearly a systems set up to encourage splitting and workplace fragmentation and it had nothing to do with anybody's performance.

      The measurements in these cases are also set up by people who don't know anything about measurement. The think up a scale and therefore it is valid.

      There is a reason that business major don't go to medical school. At least they didn't when I was there.

  5. Having retired 13 years ago, I pretty far down the road from where I was when I had similar kinds of reflections. And while our careers in psychiatry differed, I had similar thoughts. I could never have predicted how they would play out in retirement. The end of the story is that I volunteer in a rural charity clinic, I maintain a blog focused on a topic in psychiatry far from the area I worked in while practicing, and I continue to teach. The thing that surprises me is that I thought, as you are thinking, about what I might contribute. What I've found is rather how much I've learned, given the time to think away from everyday practice...

    1. Thanks Mickey,

      Time to think is always at a premium. It is also one of the useful effects of teaching. One of my attending Endocrinologists pointed that out to me when I was an Intern. He said that there is no better motivation for learning than having to show up for rounds and prove that you know more than the fellows, residents, and medical students. I recall him easily outdistancing us on all of the stages involved in the adrenal production of corticosteroids and mineralocorticoids. And of course he knew all of the evaluations for the problems along the way.